Science, Policymaking And The Pandemic. Q&A With William Haseltine
(Posted on Monday, December 14, 2020)
Below is an interview between Matthew Bishop and William A. Haseltine on the Driving Change podcast. Listen to the episode here on the Driving Change website: https://drivingchange.org/science-policymaking-and-the-pandemic-qa-with-bill-haseltine/
William Haseltine (WH): During this pandemic we’ve seen a disrespect for science and, at the same time, a deep hunger for science and for rationally based medicine. Writing this autobiography, my primary motive is to encourage young people to become scientists, to show that it is a very fulfilling life, and that science is an area where one person can make a difference in the entire world through the work of their mind.
I’m writing a new version for kids aged 10 to 15, called “Science As A Superpower”. It is a superpower precisely because it can allow one person to change the world for the better. You think of Louis Pasteur, James Watson, Francis Crick, Jonas Salk – one person can change the world. It’s a great feeling. And even if you don’t change the whole world, you can make it a better place. It can be a very rewarding life.
I just wrote an essay about the Pfizer vaccine [positive trial results had been announced just before this interview]. Like all great scientific breakthroughs, the vaccine has a deep backstory. The first is massive US funding of biomedical research for a period of 50 or 60 years. That’s been my whole career. It has funded a really deep knowledge of viruses and biomaterials.
Then there’s that spark of genius: Bob Langer, who has contributed to so many new inventions by applying biomaterials to medical problems, in this case, how to package RNA in a way that it can get into cells and do its work. Decades and decades of work and success and failure. Bob and I started a company together to make vaccines more potent; he finally found a better way to do it than the way we had been doing it.
But it’s really decades of work combined with the power of a very sophisticated financial system to take ideas from universities and move them forward through venture capital, through initial public offerings. I’ve been involved in that system, which we use again and again, with the support of enlightened legislation that says there’s an obligation for universities to transfer intellectual property to the private sector. That’s part of the whole story behind this Pfizer announcement. Whether it turns out to be the answer to COVID-19 or not, it’s a great story.
It may well be part of the answer to the problem, but we can’t say that with any certainty since we only have the announcement not the data itself. I’m all for speeding up work on COVID-19. But I’m not for making announcements where you don’t present the data to analyze. I’d love to have seen the Pfizer data. All we can rely on at this point is the reputation of the CEO and the company. They believe that what they tell us is correct. But when you look a little deeper, you look at the protocols, you realize the vaccine they’re trying to make doesn’t prevent infection, may not prevent serious disease, or death, and may not really prevent transmission, all those things that everybody ideally wants in one vaccine. It might be like the flu vaccine. That’s, I think, what it is looking like.
I’ll point something else out that most people would probably not realize. If you are infected immediately after your last vaccine boost, which the people were in this trial, you’re not actually measuring the vaccine, you’re measuring the antibodies to the antigen you put into the people. A vaccine is actually recalling memory from an experience you’ve had some time ago, not pumping up your antibodies. We will have to wait to see whether this will actually induce some memory response, which is what we depend upon for antibody protection or vaccine protection. There are a lot of unanswered questions. All of that being said, this is good news. We just don’t know how good the news is.
Driving Change (DC): Looking at how the world has responded to this pandemic through public health policies, it seems clear that many of the actions have been ill-considered and poorly executed. There has been little learned from history. On the vaccine side, however, and the search for treatments, there seems to have been a much more impressive effort, one that really we should be proud of, and that has a reasonable chance of succeeding far faster than anyone would have imagined. Am I right in that assessment?
WH: This is absolutely reminiscent of HIV/AIDS. The medical and scientific world was excoriated for about four or five years for not paying attention to AIDS. This criticism was fair regarding public health policy, it was fair for the government, for the Centers for Disease Control and Prevention (CDC), the department of Health and Human Services in the US, and for most other government agencies. But it was not true of science. Science got right to work. It identified the virus, even faster than we thought possible. It found drugs, diagnostics, and other tools to deal with this disease.
The same thing has happened here. The response to this pandemic, in Western countries and in Southeast Asia, has been abysmal. You don’t have to look at history. You can look to China, a country of 1.4 billion people that now has no COVID-19 infections. Three weeks ago, millions of Chinese traveled all over the country without a single infection. We shouldn’t be criticizing them, they are basically free while we are still suffering. They can go to theaters without masks. Their restaurants are packed. They have large gatherings with no problem. That’s the reality of China. The only thing they can’t do is go outside their country because it’s a COVID-filled world. That’s why they’re very careful about people coming in.
The lesson: you can control this disease with public health measures alone. So many people refuse to believe it, even when it’s before their very eyes. Belief is very powerful. The human mind is always emotional and sometimes rational. It’s the emotions that cloud our vision, so we can’t see reality. We can’t see that this is totally controllable.
We in the West are instead relying on science to save us. Well, science can contribute, but it’s not like in a movie where it happens overnight. We’ve put AIDS partially back in the bottle with drugs and we may be getting a vaccine finally, so that there is one shot protection, for four or five months, from getting HIV. That’s good. But it’s taken us 35 to 40 years to get to this place. Even though we’ve shortened the time it takes to mobilize our scientific efforts, it still takes a long time.
The Trump administration has put all its hope into science, not public health, and that’s deeply misplaced; you’ve got to do both in this pandemic. A lot of people are going to die because of that very poor decision. You can argue that they did do some things right. For example, they were right to pour in tons of money to vaccine development. However, by trying to twist the rules—I call it drum warping—of the regulatory process through Operation Warp Speed, they have done nobody any good. It just builds distrust. We’ve got to have things done by the book. The Pfizer vaccine announcement was not done by the book. People stand to profit enormously from some of these announcements and that’s just not right.
DC: To what extent have philanthropic efforts by Bill Gates and others been important in getting this vaccine strategy as far and as quickly as it has come?
WH: The Gates Foundation has played a key role in the development of vaccines in general and Covid-19 vaccines in particular. The Foundation has promoted vaccines for use in the US and globally for years and helped to pay not only for their deployment but also for technologies that make new vaccines possible.
Vaccines are the best tool in our medical arsenal for combatting the disease. Those that work well can prevent pandemics and, in some cases, eradicate a disease. Vaccines are also the most cost-effective tools in our medical kit.
My foundation, ACCESS Health International, works on assuring people access to high-quality affordable care no matter where they live, no matter what their age. Why did I pick that area? Because after seeing the great promise of genomics, and all the progress in bringing new medicines to market a big problem turns out to be access. In many parts of the world, even in the United States, access to affordable care is a problem. There are tremendous inequities in health care services, so bad that even if there is a drug that addresses a specific need, that drug or treatment may never reach those in need.
Let me recount a personal experience. I was on the board of a Gates Foundation-sponsored clinical trial of a drug to treat visceral leishmaniasis. The drug was approved by the Indian FDA but, in the end, no one was able to benefit from the drug because the infrastructure in Bihar, the region that suffered most from the disease, was so poorly developed that they could not deliver the drug, even at no cost, to the people who needed it. That experience taught me the importance of health systems. Much of the work of ACCESS Health is devoted to health system strengthening.
Vaccines may, under some circumstances, be effective even in countries with poorly developed health systems. They can be administered globally by an international organization, regardless of the underlying infrastructure. That’s the difference. An international agency can sweep through a country. That’s how we got rid of smallpox. It’s how we’re about to get rid of polio.
One of the engines behind the Pfizer vaccine is the Gates Foundation, which made their bet and put their effort into these brand new vaccine technologies, which Pfizer has used. I think they’ve done a great service to mankind.
DC: One of the issues that will, I guess, come to the top of the political agenda globally, once a vaccine is effective enough to be distributed, is equitable distribution. That’s going to be a huge challenge, as there’s not going to be enough produced in the next 12 months of whatever vaccine works to get it to everyone. How do we handle this?
WH: You are correct. For the first few months, the supply of vaccines will be very limited and very expensive, at least for the governments that purchase them from the US or European pharmaceutical and biotechnology companies. The Chinese and Russian vaccines may be much less expensive. There will be major inequities within and between countries. The cost and regional inequities will eventually be resolved by countries such as India that will supply the world with low-cost effective vaccines that are suitable for use in resource-limited settings.
That has been the story of HIV/AIDS medications. At first, they were very expensive, costing tens of thousands of dollars per year and available only in high-income countries. Eventually, they were made by generic companies, mostly in India, and cost less than $100 for a full year prescription.
Indian companies are capable of producing very large amounts of vaccine. They produce two-thirds of the world’s vaccines today, mostly for low-income countries. I think we can rely on the manufacturing capacity in India to supply much of the developing world with the Covid-19 vaccines they need at an affordable price and if not India, China.
Some of these vaccines, like the Pfizer vaccine, are unsuitable for poor countries, because of the cold chain requirement. The problem with others, like the adenovirus vectored vaccines of Astra Zeneca, is that they cannot be used more than once. I believe it likely that people will need to revaccinate annually or biannually. Other types of vaccines are being developed that are more suitable for use in low-income countries. Unfortunately, it may be two or three years before they are widely available.
DC: I want to pick up on the point you made about China. One of the critiques that Western politicians have made in their own defense of China is obviously that it has a somewhat different view of people’s privacy and their freedoms in all sorts of ways that we take for granted here. This is why the Chinese approach couldn’t be taken in the West. What do you think about that?
WH: Quarantines were invented by the Venetians. What was the original quarantine? If a boat arrived at a port with a sick person abroad, the ship was required to anchor offshore. No one could leave the ship for forty days. Those who survived were free to come ashore. Entire cities were closed during the Renaissance in times of plague.
We know how to design, implement, and enforce quarantines. We have the laws to do it. The declaration of an emergency power gives us the power to do it. One of the great tragedies of the Covid-19 pandemic in the United States, Europe, and South America is that we have not used the power of the central government to enforce quarantines. The recent Supreme Court decision to exempt church gatherings from public health control measures is utterly misguided and must be overturned. The decision is equivalent to ruling that if you are an alcoholic it is permissible to drive while drunk. Those who gather for religious purposes in times of plague endanger not only their lives and those who attend the services with them, but also those in their communities as well. I will not be surprised if many secular activities now seek to be reclassified as gathering for worship!
The Romans ruled long ago that public health is the greatest good. The demand for public health trumps every other right. We restrict our right to drive while drunk or smoke in restaurants because it harms others. Surely, we have the power to control behavior that can kill hundreds of thousands, if not millions, of our fellow citizens? We do have the power, but we choose not to use it.
General John Allen, the President of the Brookings Institution, and I have called for the creation of a presidential Covid-19 Commission, like the 9/11 Commission, to examine leadership, to examine governance, and to examine all the laws and how they’ve been enforced. Such a commission will look at what failed and how to restructure public health governance and pandemic preparedness.
We need to do better. I think it very likely that Covid-19 has become an endemic human disease. It will come back again and again and again to get us, just like the cold-causing coronavirus cousins of SARS-CoV-2. Even with a vaccine, Covid-19 will most likely resemble the annual influenza pandemics. Vaccines may reduce the toll of death and disease but are unlikely to eliminate Covid-19.
In the meanwhile, we are in the midst of a roaring pandemic as we speak on the eve of Thanksgiving here in the US. The cavalry may be on its way, as Dr. Fauci remarked, but the fort is burning.
My solution? Covid Control American Style: Universal, self-administered home tests coupled to paid home isolation with family. The federal government should produce enough rapid tests to detect SARS-CoV-2 so that everyone in the country can test themselves at least twice a week. I estimate that would be about a 150m tests per day. Free rapid tests should also be distributed to businesses and to schools. That will allow people to know in real-time if they are infected and possibly contagious.
Testing should be a prelude to the isolation of all who are potentially infectious. Individuals or cohabiting families with one member testing positive should be paid $500 a day to stay home if they’re infected. Local public health officials should retest before paying. Family isolation should be complemented by legislation that ensures families receive additional sick leave and cannot be terminated for failing to show up for work.
DC: How much would that cost?
WH: I think you can put the genie back in its bottle in about three or four months for no more than $200 billion for the US. But even twice amount would be an enormous saving compared to the $16 trillion we’re already in the hole, and going deeper. $16 trillion is a conservative estimate, as it does not include the value of the lives lost.
We know public health measures can control the pandemic. China did it. Their program was mandatory isolation for all those potentially exposed to SARS-CoV-2. We can be more efficient, thanks to rapid tests, focusing only on those who are contagious and their immediate family contacts. That is a much smaller number than those potentially exposed.
DC: A challenge you note in your book is that we don’t live in a culture that truly respects science. It’s very hard for governments to use scientific facts to persuade people to behave coherently, in sensible ways, even in their own self-interest. And that’s probably why you’re proposing to offer them money to stay home because money is the one thing that people do still seem to understand in a relatively rational way. What can be done to restore trust in science?
WH: I find that most people hold two somewhat opposing views about science. On the one hand, they’re very grateful for the benefits of science and technology. They’re very grateful for medicines that may save their lives and cure their ills. People are very grateful for the communications technologies and even grateful for the low prices of goods that globalism makes possible. But many are worried about something else altogether—erosion of the way they live—and they see science and technology as part of the problem. Do they have respect in their jobs? What is the role of a man or woman in society? Are people respected for the work they do? Is the family structure threatened?
This dichotomy is evident in the Trump administration’s approach to Covid-19. On the one hand, dismissing public health measures. On the other, spending billions of dollars to speed the development of a vaccine. Trump is not anti-science. He’s anti-public health.
DC: Do you see parallels with how politicians responded to HIV/AIDS?
WH: Yes. In both cases, the President, the administration, the CDC and the US Department of Health, Education and Welfare denied the serious nature of the new disease and were slow to activate a national public health response. Denial and delay killed many people with HIV and are killing people with Covid-19 today.
The exception to denial and delay for both diseases has been the response of the medical and scientific establishments. Both for HIV/AIDS and Covid-19, doctors recognized the problem early, sounded the alarm, and did whatever they could to keep people alive. Scientists around the world quickly mobilized their resources to understand the new disease, describe the new viruses, develop diagnostic tests, and initiate efforts to develop drugs and vaccines to treat and prevent the disease. The speed of the development of diagnostic tests and drugs (for HIV/AIDS) and vaccines for both diseases proceeded at unprecedented speed.
There is another similarity. The rapid progress in HIV/AIDS research was made possible by twenty years of generous support for cancer research, most specifically the Nixon era War on Cancer that continues today. The War on Cancer provided the tools we needed to understand HIV/AIDS and how to combat it. The rapid progress on Covid-19, especially the vaccine development and clinical trials owe much to the thirty years of generous funding of HIV/AIDS research. New procedures initially created for the rapid approval of HIV/AIDS drugs changed fundamental aspects of how the FDA evaluates and approves new drugs. I believe Covid-19 will shape the way new vaccines are evaluated in a similar way.
That being said, there are important differences between the two pandemics. The HIV/AIDS pandemic spreads slowly but has killed many more people than has Covid-19, about 37m, and still kills about a million people per year. No vaccine yet exists that is effective, but many drugs prevent disease and some prevent infection. Covid-19 spreads quickly. It is likely that vaccines will prevent disease and may slow the spread of the virus. Antiviral treatments are also likely to work but the window for effectiveness for Covid-19 is measured in days. HIV/AIDS responds to drug treatment for years.
Another difference between the two diseases is government funding for research. Funding for vaccine and drug development for Covid-19 has been almost instantaneous and copious. Serious funding for HIV/AIDS research was delayed for at least four years from the identification of the disease. I think it is likely that the difference is due to the severe economic impact of Covid-19, not to lives in danger. Covid-19, if uncontrolled, has the ability to devastate economies, in a way HIV/AIDS does not, at least in high-income countries.
My experience with HIV/AIDS and later as chair and CEO of Human Genome Sciences taught me valuable lessons about the interface between science, medicine, and health systems. One of my motives for creating the foundation I now chair, ACCESS Health International, was the realization that health care costs are rising so fast in the United States that they’re undermining every other social service. They are undermining our military, they’re undermining our international competitiveness in businesses. I fear the rising cost of healthcare in the United States will eventually undermine our ability to find new medical solutions. People are going to say, “You’re breaking the bank, to hell with these new solutions. Let’s just use what we’ve got”.
ACCESS Health now focuses on what is necessary to deliver high-quality care at a cost the economy can bear. I wrote a book Affordable Excellence, illustrating the point. Singapore delivers much better medicine than we do at one-quarter of the cost, 5% not 20% of the GDP. I wrote another book, World Class, that looks at the same problem from a different perspective. The question posed by World Class is not what government and health policy can do, but how can an individual health system improve patient care themselves. A renewed focus on excellence transformed NYU Langone Health from a failing, mediocre academic medical school to one of the best in the world in patient care, teaching, and research.
DC: A question about the anti-vax movement and what we do about that. When we do have a vaccine, it seems like there’ll be a lot of people that say, “Well, we can’t trust it, we shouldn’t take it”. How do we counter that movement?
WH: Well, the first thing is, our current president is now a big vaxxer. He was an anti-vaxxer. It is very peculiar to hear him say, “I’m going to save you through a vaccine”. Many of the anti-vaxxers are Trump supporters. Maybe a jujitsu flip would be for him to be an advocate for the Covid-19 vaccines, in the US and abroad. I think the anti-vax movement is one you can handle if you’re careful, and you have the right spokespeople.
Operation Warp Speed has raised a lot of questions over processes, such as the FDA statement that they do not intend to inspect the facilities that manufacture Covid-19 vaccines. That is shocking. Inspection is a necessary step to assure the public that vaccines are safe.
The anti-vaccine movement is not a problem restricted to the United States. If you talk to any of the international organizations that deliver vaccines, they will say that at least half of their work is getting local community leaders, who are respected in the communities, to speak on behalf of the vaccine. It’s not easy to get people to accept something they may not think is right. You must work at the community level. You can’t work at a level above the community if you’re trying to change belief. You don’t change belief through rationality. Belief dominates rationality. You have to do it through trust.
DC: If you were a policymaker today, in government, what would you do to encourage more people into science?
WH: I don’t think we should underestimate presidential leadership. I came to political consciousness during the Eisenhower years, the Sputnik years, the Kennedy years, and even the Johnson years, and they were so pro-science. All our science curricula were rewritten. There were tremendous incentives to pursue science. Society kept opening another door in front of me as I went along my path, whether that door was a new physics and chemistry program in high school; whether that door was special programs for the science-oriented; whether it was senior professors fishing into that sea of 3000 chemistry students to find a couple of likely fish that could become scientists; whether it was Harvard creating a program for people who wanted to go from physics and chemistry into biology; whether it was postdoctoral fellowships; or startup grants for young professors; or new facilities to do work with biohazardous materials; whether it was venture capitalists offering the money to help me create companies. All of that is people opening doors to follow this path.
That’s what you need to do again now. Kids are trying to figure out “How am I going to get on in the world?” If they see an open door, they’re going to head that direction. And so our society has to do all the things I just mentioned. And I hope I can open the door for a few others to come after me.
DC: So you believe there are a whole lot of doors that could be created that aren’t there at the moment?
WH: Absolutely. Starting with the president saying science is where we have to go.
DC: Any final thoughts?
WH: My new book is also inspired by Abdul Kalam, the President of India from 2002-2007: a Muslim, from an unbelievably poor background who rose up to become the head of his country. His entire life was devoted to science. When I knew him, he did everything he could to open the doors of science. He would visit every laboratory, go to every biotech company, every pharma company: there are so many plaques commemorating Abdul Karam visits. He wrote six books, for kids, to help them become interested in science.
Most people may know him as India’s Rocket Man: he was also their atomic bomb, man. He was a very interesting character, one of the most interesting characters. He helped that whole continent, even coining the term “knowledge economy”.
India has echoed in important ways what was being done in the US under Eisenhower and Kennedy, for young people. And the results in India have been spectacular. It has also benefited us in America because a lot of those young people are now running our tech industry. I hope that we can rediscover those ways and one day return the favor. My hope is my recently published autobiography, My Lifelong Fight Against Disease: From Polo and AIDS to Covid-19, together with the version I am now writing for young people ages 10-15 years old, will encourage young people to become scientists and doctors.
Note: This interview has been lightly edited for clarity and context.